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The WebSurg World Virtual University originates from the success of the Institute for Research into Cancer of the Digestive System (Institut de Recherche contre les Cancers de l'Appareil Digestif [IRCAD]) International School of Surgery. The concept of this school is to unify academic teaching and tutorials delivered by international experts able to share and confront their opinions about the most recent approaches in laparoscopic surgery. To overcome the geographical constraints of the school located in Strasbourg, France, we had to envision an original way of reproducing this concept and make it available anywhere in the world, with no time and access restrictions whatsoever: The Internet stood out as the solution.

The new means and modalities of communication and information technologies have significantly revolutionized the access to surgical education. The introduction of the Internet information highway into mainstream clinical practice as an information-sharing medium offers many opportunities to healthcare professionals. The Internet favors an easy, worldwide diffusion of scientific information. As a result, daily surgical practice shows an increase in the use of the Internet to gather, transform, and disseminate surgical data.

In earlier years, access to information was primarily done through paper (journals, books, etc.). The impact of the Internet on information diffusion is indirectly confirmed by the irritation of the traditional book publishers facing the intent of Google, one of the major Internet providers, to digitize and index the library collections of major research universities [1]. The Internet, with its capacity to federate all networks, is progressively superseding all other education media. In addition, the Internet appeals to the surgical community with its main characteristics, i.e., interactivity, multimedia user-friendliness, and quick access to and low cost of information. This cybermedicine allows sharing of data with an unlimited number of Web users including patients or industrialists. The notion of universal information exchange represents the benefit of the Internet, based on sharing of information. Each user may find his or her field of interest in the wide range of data available. Since nowadays almost every physician is connected to the Internet, and thanks to the quality of specific search engines specialized in medical publications such as PubMed or ones more generic such as Google, surgeons have the ability to use the Internet in their practices. The surgical community can easily find extensive theoretical and practical information that may be used in order to acquire, test, and validate new operative skills from any geographical location in the world. Physicians, and especially surgeons, spend a considerable amount of time in educational activities. It is confirmed by the growing number of continuing medical education (CME) credit points delivered each year through educational websites (approximately 10% of all delivered CME credit points) [2].

Both surgeons and information providers (universities as well as the industry) quickly understood the attraction of virtual learning and its convenience. The Internet allows independent work whenever and wherever possible. Online information is available everywhere, 24 hours a day, and 7 days a week, with no constraints of time or space. In this respect, surgeons may continue to provide care for patients while improving their knowledge and practice skills. Additionally, they may remain connected to their favorite website and concentrate on surgical indications, or watch videos and descriptions of conventional or new surgical procedures.

A recent search performed on Google using generic keywords like "education" and "surgery" listed more than 9,800,000 websites (Table 4.1). The extraordinary amount of websites found there represent not only reputable educational information but also millions of websites run by individuals, business, advocacy groups, and clubs, serving different intentions and audiences. Sorting out such a massive amount of material, one kernel of medical information often appears to be frustrating. The frustration raised and unreliability of certain sources of information drove some surgeons to develop high-quality, specialized, and dedicated websites. Thanks to such specialization, online educational activity is gaining more and more acceptance [3]. To support this evidence, a survey was recently administered by Gandsas et al. [3] to members of the Society of American Gastro-Intestinal Endoscopic Surgeons (SAGES). Respondents were recruited to participate through a mass e-mailing or by visiting www.laparos-copy.com. In this study, 78% of the respondents used the Internet to expand their knowledge of surgery, 74% to learn about the technologies related to the practice of surgery, and 68% to locate resources for academic purposes. The power and potency of these dedicated websites is directly correlated with their quality. We developed an original multimedia website, www.websurg. com, whose contents are written by surgeons under the control and seal of approval of national and international scientific societies (Fig. 4.1).

The prerequisites for success have been met: a technological quality with a real use of multimedia and, notably, video streaming techniques may be observed. There is also a respect for cultural diversity, and reliability. Quality is the key factor for success in the long term, even though its price may be high. Quality means having the best, most renowned authors whose content of their chapters and videos must be checked and approved of by a peer review committee. The peer review process seems to offer a guarantee of good quality, but it also has its pitfalls when human behavior is involved and when disagreement occurs between individuals. Quality is assured with a strongly built editorial line and is gained over the years. An academic environment helps to raise quality standards. Many tools are being developed to upraise the quality of Internet products [4]. Some authors argue that it may be impossible to guarantee the quality of medical websites [5].

It is easy to point out that quality is poor on the Internet, but today it can be demonstrated that long-lasting success remains the easiest way to confirm the quality of specialized websites. A specialized website must include all the components of an educational system. To be identified as one of the best educational systems in the world, it must provide a system of worldwide information diffusion with the participation of world-renowned experts. The WebSurg site tries to fulfill these requirements in order to stay at the cutting edge of the virtual education in minimal access surgery. The website is geared to represent the model of the Internet-based virtual university specialized in minimally invasive surgery. The surgical contents are classified into different fields of surgery (e.g., general and digestive, urology, gynecology, endocrine, etc.). A wide range of multimedia technologies helps to maximize presentations of surgical data.

Table 4.1 Results of Google search, 9 March 2005

Keywords

Figures

Training surgery

8,400,000

Education surgery

9,860,000

Laparoscopy surgery

296,000

Laparoscopy education

128,000

Laparoscopy training

116,000

Fig. 4.1 WebSurg website

4.1 Surgical Operative Techniques

The core of the website is made up of surgical operative techniques. One hundred fifty procedures in minimally invasive surgery have been described and posted online. The content of these chapters has been designed for multimedia education and learning. Internationally renowned experts were invited to write texts and send ideas for illustrations. Editors and illustrators worked out an original way of processing such information to provide topnotch illustrations and pictures suitable for visualization on any computer screen. New technologies allow rethinking of the anatomical artwork in order to achieve the best representation from a surgical standpoint. Dedicated software such as Macromedia Flash® technology makes it possible to provide animation to still images. Unlike other media or paper journals, the Internet offers color illustrations, animations, and videos, with no limits in size and number. Internet-based techniques follow the evolution of the technology. Every year a new multimedia version permits to improve the quality of artwork and drawings, to implement new educational tools, as well as to upgrade the existing chapters of operative techniques. The worldwide diffusion of the website mandates an adaptation to the surgeons' culture. For this reason, many chapters are translated into several languages. English, the international language, is complemented with translations into French, and Japanese. At the time of this writing, translation into Chinese was anticipated by the end of 2007. Recently, new software allowed and enhanced navigation with many functional options including full screen display of information, slide shows, as well as an easy and permanent navigation through the entire chapters of operative techniques with one single mouse click (Fig. 4.2).

4.2 Video Footage

The training of surgeons is continuously making progress with the establishment of structured training standards and criteria to enhance cognitive knowledge by integration of basic science. This has an impact on the clinical and operative skills of surgeons. At present time, videos represent an essential asset of education in minimally invasive surgery, and the rapid evolution of the technology allows high-quality video footage to be made available on the Internet. This possibility will assuredly strongly modify the access to surgical education [6]. The broadcasting of videos through the Internet has been facing technological limits for many years. However, the high-speed Internet broadcasting at present time available (cable and DSL, 512 Kbps and higher) allows the displaying of high-quality, full-screen videos through the Internet. As an example, the WebSurg website gives permanent access to 265 videos of surgical interventions. The evolution of technologies offered Web users the choice of video bandwidth compression for an optimal, high-definition view of the video footage. Each new video published on the website is dis-

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